Apollo Root Cause Analysis – A New Way Of Thinking

Copyright 1999 By Dean L. Gano; dgano@apollorca.com Editors Note: The following chapter has been modified slightly to accommodate the website presentation. Chapter One provides valuable insights into why 70% to 80% of the population are less than adequate problem solvers. This sets the stage for the rest of the book, which discusses the cause and effect principle and a set of simple tools that will significantly improve your problem solving ability.

Chapter One: Set Up To Fail
Ignorance is a most wonderful thing. It facilitates magic. It allows the masses to be led. It provides answers when there are none. It allows happiness in the presence of danger. All this while, the pursuit of knowledge can only destroy the illusion. Is it any wonder mankind chooses ignorance? In every human endeavor, a critical component to our success is our ability to solve problems. Unfortunately, we often set ourselves up to fail with our various problemsolving strategies and our inherent prejudices. We’ve typically relied on what we believe to be common sense, storytelling, and categorizing to resolve our problems. Conventional wisdom has us believe that problem solving is inherent to the subject at hand—the doctor solves medical problems, the mechanic fixes our car, etc. Using the strategies most of us have learned in our lives typically leads to conformity, which brings complacency and mediocrity. This chapter will dispel these false notions and many others that prevent us from being effective problem solvers. As we explore the reasons behind ineffective problem solving, we will see how rule-based thinking creates the illusion of one right answer and a misguided belief in common sense. We will also see how our natural prejudices prevent effective problem solving. By dispelling the notion of common sense, we are able to replace it with a common reality that allows extremely effective communication. By appreciating all views and seeking causes, not blame, we will start down a path that leads to effective solutions for everyday problems every time. Please open your mind and join me on an adventure into a new way of thinking that will improve your problem-solving skills and enable much more effective communications. Problem solving is generally understood to mean overcoming some kind of difficulty by implementing a solution. The best solutions are often the most difficult to find, not because they are hiding but because we don’t bother to look for them. We call these untapped solutions creative solutions because they are seemingly created from inside our minds. Like the sculptor’s notion that the statue lies within the stone, many effective solutions are waiting to be revealed.
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Depending on the various abilities we start out with, combined with the experiences we encounter in life, we each develop our own strategies for coping with life’s problems. We each define our own world by creating our own reality. We observe how different things interact and establish our own understanding of the world through these relationships. We learn to control various causes (for example, people and things) to obtain certain goals. We do all this without even knowing it. It is simply part of our nature to explore and understand the world around us. Problem-solving skills vary significantly from person to person, and most are ineffective. The notion of a single right answer, the belief in something we call “common sense,” and the natural tendency to establish biases and prejudices are all strategies that block effective solutions. This chapter will explore some of these strategies and where they come from. Problem Solving One of the most difficult questions I am asked as I travel around the world is, “What do you do for a living?” The answer to this question is difficult because most people are not familiar with what I do. My usual response, “I teach people how to be better problem solvers,” is understood in many ways, but rarely as I intended. “Oh, are you a psychologist?” “Oh, are you a college professor?” “What kind of problems?” “Are you a management consultant?” I am frustrated because I can’t think of any other way to summarize what I do that will be understood. Every response reminds me how each person perceives the world differently and how the notion of problem solving has no common meaning. Pondering why this is so, I wonder if it may be because our education systems do not recognize problem solving as an entity unto itself. Since problem solving has never been established as a separate subject or curriculum, our skills are not well developed. Aside from the sometimes boring and difficult dictums found in college courses on logic and critical thinking, no fundamental principles have been laid down on which to build a problem-solving curriculum. Problem solving is understood to be inherent in each subject, so problem solving for the computer engineer or the mechanic is thought to be unique to their occupations. Based on this belief, we have failed to teach effective problem solving. I have discovered that while specific knowledge lies within the job, profession, or subject matter, effective problem solving can be universal to all subjects. Certainly most mechanics can’t solve highly technical computer problems nor can the typical computer engineer be expected to rebuild an engine, but they both can use the same problemsolving strategies in their work and their lives. While problem solving can be categorized in many ways, we usually treat problems as if they are rule based. That is, we seem to believe all problems have “one right answer.” A colloquial saying even expresses this notion: “It’s the right thing to do.” Many people are so intent on solving all problems with rules that they limit themselves to the same old favorite solutions that failed to prevent them from recurring in the first place. Rule-based problems follow rules created by people to help us understand repeatable events, such as a company procedure or established laws. In rule-based problems we agree to a convention, and thus a single answer or pre-defined solution is usually
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he always establishes a box around the experiment so there are no unknown variables. storytelling. He talked about Einstein and Niels Bohr and stated that “why” should never be asked. for example. I explained. most problems do not have one right answer—only good. Rule-based problem solving is often ineffective because our daily lives are filled with the immense variability of the human condition. better. We are going to examine each one of these practices. When I discovered his perspective. and the result is documented and used to provide evidence of a theory or premise. With an aversion to contradictions. I identified several problem-solving strategies that are detrimental to effective problem solving. The rule-based approach is often more concerned with conformity and consistency than with accomplishing our goals. In scientific experiments. These daily problems are called event-based problems. We so often look for one right answer because that is what we have been taught to do. I taught some of the conventional wisdom of the day.D. and best. The next section takes a look at the practices we have so carefully cultivated and refined but that unfortunately allow us to repeat our problems rather than prevent them from recurring. As such. where the decision process is moved to the lowest possible level in the Page 3 of 20 Excerpt from “Apollo Root Cause Analysis –A New Way of Thinking” 1999 Dean L.available. As we will discuss later. the root cause myth. we had many discussions over the next two days and I finally came to understand his perspective. In his world of experimental physics. everything is known. I pointed out to him that the world outside his boxes did not have the luxury of complete knowledge. Gano . physicist. the false belief in common sense and a single reality. a few students would seriously challenge what I was teaching. Stopping Too Soon In recent years. Since this was a total affront to the theme of my class. businesses have been inundated with one new management program after another. In each class. I reflected on each class and was constantly learning and changing what I taught. He understood what I had said. A Ph. the need to place blame. or three strikes and we are out. or if we run a red light we may be fined. Typical Problem-Solving Practices When I first began teaching root cause analysis. and categorical thinking. When we cling to a rule-based mindset. groovenation. a condition is changed. informed me during class that to ask “why” was foolish. In each case. The most common detrimental problem-solving practices used by individuals and organizations the world over include stopping too soon. One of the key elements of several management initiatives is the notion of empowerment. the answer is predefined by a set of rules. 2 + 2 = 4. asking “why” is an important part of my approach in identifying causes and effects in problem solving. I taught people how to categorize causes and how to find the “real” root causes. The concept of the “right answer” was brought home to me a few years back when I was teaching a class at a national laboratory. In the process. we set ourselves up to fail when trying to solve event-based problems in daily life. but it destroyed his illusion of the perfect world where everything is known and right answers always exist. who was also a tenured professor at a prestigious college. Variables exist in the infinitum.

organization.” yet most stopped this line of questioning after only two or three “whys. I don’t think they really believe in this empowerment stuff. we need to make sure they have good problem-solving skills. Only two out of every ten responses continued to pursue causes until they found enough cause and effect relationships to allow an effective solution to be implemented. As a result. “What do you mean you need more lights?” “Well. Consider the following example of an empowered work group at one of North America’s larger manufacturers. you know!” Again. No additional lights were needed. I hear a problem and a solution in the same sentence. in our quality circle the other day. Frank asked. and all they need bring to the table is their specific knowledge. Why do you think the light is so bad?” “Like I told you. the guys decided the lighting in here is no good. Frank had the fixtures cleaned or replaced and cable trays moved. While evaluating the responses is subjective. who understood effective problem solving. our building needs more lights! Is it OK for us to order new lights? I mean with this new empowerment thing. he found light fixtures covered with several layers of white paint. there ain’t enough lights in here. The people in the quality circle had a solution without fully understanding the problem. It was encouraging to find 50% of the participants immediately asked “why. I think it’s just the latest flavorof-the-month program. When we asked management for money to buy more lights. Like most management initiatives. clear trends emerge. Frank. Unfortunately. their solution was inappropriate. which was a limited nonscientific study. revealed that only 20% of the general populace understand the concept of basic problem solving.” They have failed to recognize that most of the empowered employees have been set up to fail. Fortunately for this company. Another 26% immediately expressed an opinion of the causes and offered a solution without investigating the problem. they had Frank. The survey. we should be able to just do it. and the participants were asked to place themselves into the situation and find out what happened so they could prevent the problem from happening again. right?” Seeking to better understand the situation.” their solutions either sought to place blame or were a favorite solution that seemed to fit. In about 10% of the responses. The assumption is that everyone has basic problem-solving skills. This is a significant indictment of the general populace’s problem-solving skills. The entire conversation was recorded and documented.” When they stopped asking “why. and one lighting circuit was not working. participants immediately sought to place blame. Several light bulbs were burned out. After a few disappointments with empowerment. If we are going to empower people. Frank persisted. most managers give up and go back to the old “carrot-and-stick methods. they wouldn’t give us any. or we are setting them up to fail. Gano . My own study of Page 4 of 20 Excerpt from “Apollo Root Cause Analysis –A New Way of Thinking” 1999 Dean L. can you show me what you mean?” Frank continued. Each event had an unacceptable consequence. A recent survey1 documented just how bad our problem-solving skills are. Five simple events were presented to each participant. the success of empowerment requires each person to be an effective problem solver. As Frank looked around the building for possible causes. “Hey. only a small portion of the population can be counted on to provide effective solutions. “So tell me more about your lighting problem.” “Well. New cable trays had been installed and blocked the light.

punishment causes the exact opposite behavior. but the emphasis was on personnel error. equipment failure. You cause me pain. I react.industry in the United States and abroad indicates that we only find effective solutions about 30% of the time. most of the time. we look to similar past experiences. but I also suspect that most people know they are not good at analysis so they rely on their past experience and just wing it. In effect. They have done nothing to prevent recurrence. a theological teaching. I have found that companies’ incident reports reflect the same symptoms and the same poor problem-solving skills as the study discussed above. Other minor causes were identified. or the criminal justice system that we read about every day. most supervisors and mangers are not prepared for their job. Since we perceive ourselves as mature adults. Consider the example. or prison. a military experience. The Need to Place Blame A contractor employee was driving his backhoe through the construction site when his boom struck an overhead power line. the military. and they have set someone else up to fail in the future. or customer service issue. In fact. The subsequent line break caused a power outage and disruption of work over a large area. school. but a human reaction. Stopping too soon seems to be caused by the need to get on with a solution. If we are unduly punished. The first root cause was personnel error. we place blame because we don’t know what else to do. we do not appreciate being treated as children. this failure goes beyond the incident reports to the techniques people use and the way people think about problem solving. This often causes childlike behavior. We are more likely to seek revenge or to give up. a teacher-student experience. More important than the ignorance of our actions is the causes behind them. the company. The belief that punishment will improve behavior in adults is not supported by any facts or studies. and root causes identified. we do not strive to do better. In the case of personnel error and punishment. or the country. The rational. this company probably replaced the most experienced person with someone who has no experience with overhead wires. Since this was a veteran backhoe driver (who by the way had never had an accident before). Like parents. none of Page 5 of 20 Excerpt from “Apollo Root Cause Analysis –A New Way of Thinking” 1999 Dean L. reasoning “self” may not come into play when dealing with hurt feelings and emotional pain. This is only one of thousands of examples that happen daily in American businesses. It doesn’t matter whether it is a safety incident. Gano . which we will discuss later. The fact that we seek to place blame about 20% of the time is also very disturbing because it is rarely an effective solution. and the veteran backhoe driver was fired. Since the workplace is not a family. Firing this driver is like sending an employee to an expensive training course and then firing him when he returns. we are forced to draw on other life experiences. They may have reestablished the same conditions they had before the event. If we have not developed a philosophy for certain situations. We may find them in a parent-child relationship. how will firing him prevent recurrence? Moreover. church. of course. who learned the most from this event? The backhoe driver. which is not a question of maturity or self-discipline. where punishment is perceived as an effective corrective action. In the work place. Safety investigators were promptly dispatched. Regardless of the industry. Furthermore.

It can mean the punishment or the praise of an individual to effect a change in behavior. the cause may be that the rule is inappropriate and needs review or the individual has deviated from accepted thinking for various reasons. If taught and learned. we accept it as having some value. When this occurs. A person being praised understands they should continue their behavior. because ignorance is part of being human. Indeed. however. punishment will surely follow. In the workplace we may violate established rules using the same logic. based on some evidence. that punishment will prevent recurrence of your problem. That is.” In general. While the value is obvious if it is positive reinforcement and allows us to meet our goals. It is imperative that we know the causes of what may appear to be inappropriate behavior. Unless you believe. In the long run. I accept the consequences and may modify my behavior. it will seem appropriate and cause change only if we agree with it. If the cause was to purposely bypass or violate Page 6 of 20 Excerpt from “Apollo Root Cause Analysis –A New Way of Thinking” 1999 Dean L.. we often seek revenge or take other actions to show our disagreement with the punishment. I will accept the consequences if I get caught. If the cause of our behavior is ignorance (i. we rarely see the value of punishment and will not change our behavior. the cause is lack of knowledge. but is not unusual. we accept this causal relationship as a fact of life. It seems they wanted to punish their employees and couldn’t do it with the Apollo method. positive or negative. To my great surprise. If we disagree with the rules. Using punishment to prevent problems is rarely effective. Most people learn at a young age that if they violate established rules. In this sense. it is something altogether different for punishment. so they asked us if they could change our method a little. I use a radar detector to reduce the likelihood of being caught. Not only do I know the speed limit as well as how fast I am going relative to it. knowing full well it violates established rules. we often accept the value of such discipline and change our behavior. we accept the consequences of our actions if the error is one of commission. omission) and we are punished. the Apollo method absolutely supports discipline. To agree we must see the value in the discipline. Speeding on the freeway is a good example of this relationship. With punishment. be it positive or negative. Value in punishment may be harder to accept. The thinking may go like this: “I know it’s wrong. don’t do it! I was recently informed that one of our clients wanted to modify the Apollo method to allow disciplinary action as a solution. Discipline can be two different things. Contrary to this perception.e. I am more productive. If we find that the behavior included a conditional cause of ignorance and an action cause that precipitated the event. but only under circumstances where this is appropriate. When discipline comes from outside ourselves. discipline is an act of reinforcement and comes in one of two forms. not omission.these experiences provide an effective reference for dealing with personnel performance problems in the workplace. It can be self-generated or come from outside. We have been set up to fail by our environment. he thought the Apollo method does not allow discipline. punishment for errors of omission will likely not cause a change in behavior because behavior is not the cause. When discipline comes from within. the purpose is to stop undesired behavior. If caught. but as long as I can get away with it. I may even value this discipline as helping me grow to be a more responsible adult. then punishment will not afford effective discipline. when we commit an error with purpose. Whatever the reaction. we expect to be punished if caught and we usually accept it. Gano .

if bypassing the rules is caused by the long-term failure to enforce or reinforce desired performance. Another common cause of inappropriate behavior is the failure to learn. the performers have been set up to fail by those who are responsible for leading them. then the responsibility also lies in the leadership and not necessarily in the individual worker. or controlling them such that the problem does not recur. A leader in any organization must assume the responsibility of setting an example by consistency of purpose or they cannot be called leaders. punishment will not be accepted as having value. yet it has been around for at least 40 years and in a less formal sense much longer than that. then reassignment or termination may be the best solution. If everyone is violating the rules and it is accepted practice. it is fundamental to the human condition. It seeks to remove the cause of the problem by removing the person who fails to learn. If punishment is used to prevent recurrence. because it does not seek to change behavior. Take them out of the cause path. Root causes are the causes that solutions act upon by removing. then punishment may be an effective solution. the solution is not discipline. In this case. accountability. With this understanding comes responsibility. Never rule out the delusionary ability of the human being. make sure you know why the rules were bypassed or ignored. A few people (about 5% of the population) are simply incapable of learning. but a larger number choose not to learn. and it is effective at preventing recurrence less than 1% of the time. For those who do not understand the cause and effect principle as discussed in this book. Confront all delusions head on and remember to “fix the cause not the blame. Anyone who thinks they are doing these people a favor by not removing them fails to understand they are actually reinforcing the choice not to learn. I have found one of the greatest secondary effects of training people in these methods is that they come to believe that stuff does not just happen. however. We call this “Common Law. So yes. In Common Law situations like this. but it should be applied only when we can be sure that it will prevent recurrence. Page 7 of 20 Excerpt from “Apollo Root Cause Analysis –A New Way of Thinking” 1999 Dean L. Even here. then it is reasonably considered acceptable. And that will only occur if we understand the causes. In this case.” Responsibility for your own actions requires an understanding of cause and effect relationships.” which is not only found in the history of our legal system. This cause is evidenced by repeat offenders. It is by far the most powerful attribute we possess. changing. and behavior will not be modified. Gano . The Root Cause Myth Today’s buzz words for problem solving are root cause analysis. accepting responsibility may be a difficult task. the offending person must know the causes for prevention’s sake and must understand the causes in order to accept responsibility. If we find an individual does not learn. My studies show that we use punishment as a solution about 20% of the time. everything has a cause. Sometimes we don’t see our own willful act to violate established rules.established rules. and pride in effective problem solving. punishment is sometimes a viable solution. For example. A drunk who encourages his child to drink carries a greater burden of responsibly for the consequences of alcoholism than does the child.

The overriding theme of all these methods is the pursuit of a root cause. talked to industry experts. and C caused D. In the fire example. At some point we arrive at the root cause G and since G caused A we can eliminate the problem if we eliminate G.) Because these other methods are based on this false premise. there is no accepted definition of a root cause. not root causes. After many arguments about whose real root cause was the true root cause. Over the years I began to find some things worked much better than others. not by design. Before I discovered the fallacy of root causes. If we can control the oxygen. there are several ways to prevent the fire. To illustrate this. combustible materials and oxygen. let’s look at an example problem: preventing a fire from occurring. Funny thing though. If we decide we can control all combustible material in the area. It took me about seven years of study and teaching root cause analysis to figure out why the definition was so difficult: by focusing on finding the root cause. then our prevention goal is met and the root cause is now oxygen. effective problem solving results from pursuing a preventive solution that is within our control and that meets our other goals Page 8 of 20 Excerpt from “Apollo Root Cause Analysis –A New Way of Thinking” 1999 Dean L. and tried to implement the various schemes and tools. so what is the root cause? Regardless of how hard we try. I began to realize that the focus on root causes is a wasted effort because we are seeking solutions. which appears to have a beginning and end.With these buzz words. More importantly. hence the buzz words: root cause analysis. If fire prevention is our goal. If we choose a solution that acts upon all ignition sources by removing them. I taught people how to find the real root cause. what is the root cause? We all know how to prevent fires. then the root cause is combustible material. then we can look at the causes of the fire and identify an action that will prevent it from occurring. When I tried to apply these methods. This common but misguided approach assumes causal relationships are linear and that problems are born from a single source. More importantly. I came to understand that there are many possible root causes. I took several training classes. (The Appendix contains further discussion of other methods. Perhaps this is some anthropomorphic tendency based on the pattern of life. The three causes of a fire could be an ignition source. When I first became involved in problem solving. read the few books available. a great myth has been created. assuming this is our goal. As you can see from this simple example. we must find at least one cause that we can act upon such that it meets our goals and objectives and is within our control. I was introduced to all the various methods. I looked more closely at the methods and tried to separate the parts that worked from the parts that didn’t. it is not possible to find the real root cause of a fire because there are many possible causes of a fire. and they are a function of who owns them. then the root cause of the fire is ignition sources. This false premise stems from the following linear thinking: A caused B. and B caused C. everyone just makes up his or her own definition. such as inerting a confined space inside a tank with nitrogen. on down the alphabet. To reach our goal of prevention. If we use this simple set of causes for a fire. there will be no fire. if we choose to remove all ignition sources. This single source of a problem is generally referred to as the root cause and is the basis for every other root cause analysis methodology. Gano . What I eventually discovered is the Root Cause Myth. they only deliver effective solutions by chance. we presume there is one. they didn’t help me solve my event-based problems any better than my natural instincts.

can we identify the root causes. “If I learned anything from this. We even believe that most of those around us are equally good at problem solving. Research indicates that children Page 9 of 20 Excerpt from “Apollo Root Cause Analysis –A New Way of Thinking” 1999 Dean L. Only after the solutions have been established. touch. the decision clear. “Since when did our people start checking their common sense at the gate?” Each one of us is unique. We believe that if we are able to think of it. Receiving data from the senses. smell. I once heard a chemical plant manager say. It is not the pursuit of a root cause. not the other way around. What’s wrong with some people anyway? We usually end this line of thinking by concluding that some people just don’t have any common sense. You know the ones: retrain the employee or blame management and have them study the problem. In fact. We may even question our friendship with them because we certainly don’t want to associate with idiots. we say they don’t have any common sense. we end up stopping on a single cause that may or may not produce the best solution. Our sight.Receiving data from the senses is unique to each one of us. how could this happen? Where is the common sense? The evidence was obvious. Perception exists within each mind and is a four-step process: 1. and taste are different than other people—sometimes significantly different. Our Unique Senses . Some people need glasses. When asked. Our senses are developed early in life and are a direct function of our environment. Processing the data in the mind to form knowledge. it simply means that a root cause cannot be labeled until we decide on which solutions we are going to implement. a jurist lamented. Common sense is often used as an excuse for explaining why others do not “see” things the way we do and then punishing them for it. it must be common to everyone else. we seem to believe that problem solving is the same for everyone.” Indeed. With tongue in cheek. as conventional wisdom would have us believe. 4. it is anything but common because we don’t have the same friends or the same feelings as the next person. The Illusion of Common Sense and a Single Reality When the jury in the Oklahoma City bombing trial could not decide on the death penalty for convicted terrorist Terry Nichols. In either definition. and that uniqueness is caused by our genetic building blocks and the environment in which our perceptions were developed.and objectives. Developing problem-solving strategies. it is that two people can look at the same situation and see two completely different things. Gano . hearing. This does not mean there is no such thing as a root cause. The root cause is secondary to and contingent upon the solution. Sometimes. when people don’t act according to our preconceived ideas. Establishing conclusions and prototypes. We are misled into categorical thinking that fosters favorite solutions that didn’t work last time and probably won’t work this time. others don’t. 2. Exploring why our perception is unique helps us debunk the notion of common sense. most of us believe we have our world pretty well figured out and are good problem solvers. Common sense is defined as the common feeling of humanity. They are the ones that are being acted upon by the solutions. it can be defined as that body of knowledge that my friends and I share. 3. By pursuing a root cause.

The visual cortex. We assign nouns to things and verbs to actions. Once that time frame has passed. the mind is like a sponge that simply wants to be stimulated. Each sense is on a genetically coded timeline for development. Today. If we obtain our goals with a given strategy. From this causal relationship. children may learn the strategy of whining to get their way. For example. and possibly stored.2 The brain reserves certain areas for each sense. we will adopt or drop a given strategy. sensed data is organized and stored as knowledge. even though the eyes are completely functional. Everything is sorted. the sensory cortex along the sides. on goes the development of our senses. if a child is completely blindfolded for the first three to six years of life. The ordering process is what we call strategies. an infant may learn that crying causes hunger to go away because it causes someone to feed him. When we are young. prioritized. and every person uses Page 10 of 20 Excerpt from “Apollo Root Cause Analysis –A New Way of Thinking” 1999 Dean L. For example. in some cultures animal sacrifice is a holy event. and so forth. Our Unique Strategies . We all have our own interests and abilities based partly on the environment and partly on our genetic makeup. is located at the rear of the brain. Physicians have found that covering one eye of an infant for a short period of time (a week or more) will likely cause that eye to be less developed than the other one. such as New York. in others it is cruelty. As each sense is stimulated. This knowledge is structured and valued in various ways but is always shaped by our environment into a unique perception of the world. The acuity of each sense depends on the richness of the environment to which it is exposed during the window of opportunity. had little time left for learning beyond what was required to survive. Depending on reinforcement from our environment. Our Unique Knowledge . While we share many common characteristics. it is processed into categories for economy of thought.who are visually entertained in the first year of life establish more neural connections and hence have more active minds. such as our recent ancestors. Gano . survival is much easier and knowledge is abundantly available to most people. The development of each sensory portion of the brain is a function of the genetic structure of the mind and environmental stimulation.A key aspect of perception is how we order knowledge. the sight portion of the brain will not develop and the child will never see. With this abundance comes a greater diversity of thought. the sense will all but stop developing. The resulting personalities and perspectives would also be quite different. neurological connections are being made in the respective portion of the brain. The more time spent learning. such that every person senses the world differently and creates his or her own unique sensory perception. For example. And so. there is little judgment going on. we will retain it as part of our belief system. Growing up in Africa with Jane Goodall as your mother would provide you with different knowledge than if you grew up in a poor neighborhood in a large city. Patterns are recognized and value assigned to each stimulus in each sensory portion of the brain. resulting in the need for glasses3 and in a different perspective of the world. for example. the greater our knowledge. we each possess our own unique knowledge base. A person who is preoccupied with survival. Each strategy becomes part of the mind’s operating system.As data or information is sensed. Over time.

No two people will hold the exact same set of prototypical truths. For example. The notion of common sense is therefore an illusion created by the false belief in a single reality. Whatever the cause. we naturally establish prototypical truths that are the best we know now but are subject to change given strong enough reasons to do so. is the prototype strategy. what is reality or truth? This question of the ages continues to haunt us.different strategies for dealing with life’s problems. Understanding this uniqueness calls into question the notion of common sense. and developing strategies. some more so than others. By understanding the biological impossibility of perceiving the world the same. It is always open to new possibilities but to varying degrees. our conclusions cause a unique perception of the world. We know from past experience that sometimes things don’t happen exactly as they did the time before so we reserve the right to change our belief system. in the business world one person may use the strategy of building networks to advance whereas another might use the strategy of working long hours on many projects. but the answer is quite simple if you can grasp the notion of relativity. Gano . If we all hold the same beliefs. we have been set up to fail.The mind is continually sensing. While we use many tools and strategies for doing this. and the best we can hope for is to find a way to incorporate others’ truths into ours. We hold our belief systems open to change by the use of a prototypical conclusion. we seek validation of existing beliefs (knowledge and strategies) and do not like change. however. your first perception may be one of disbelief. Or. Once again. Inherent in our operating system. combines to form unique people with unique prototypical truths. Perhaps this need for a single reality is created by our desire to get along with one another. Our unique perception of the world. Hence. One person may find success in stealing. if perception is reality and everyone’s reality is unique. In effect. the belief in a single reality is one of the greatest barriers to effective problem solving I have found. knows this is not valid—the earth does move and it can move violently. however. As adults. Page 11 of 20 Excerpt from “Apollo Root Cause Analysis –A New Way of Thinking” 1999 Dean L. not even conjoined twins who live in the same environment. the notion of a single reality can now be seen as the illusion it is. What does it mean to have common sense when not a single person has the same view of the world or holds the same belief system? Indeed. what is real? What is reality? Can we know it? When we use the word reality. Anyone who has experienced an earthquake. while another finds failure. We each hold our own truths. All these factors are continuously evolving. Our Unique Conclusions . they often fail and understanding is left wanting. coupled with our unique interaction strategies. If you have felt the earth move under your feet or have seen a wave in the earth move across a field. we assume that there is a single reality and everyone can see it. where “best” is unique to each person. but you soon change your belief system to accommodate the evidence. such as team building. we could always agree. So. for most of us the earth does not move under our feet and this is the truth. Everything is relative to our own unique perceptions. but there is clearly no way to be anything but unique individuals. Once again. ordering. each person will determine the “best” strategy based on their own experiences.

The brain is made up of billions of cells known as neurons. and we continuously seek validation over other possibilities. It is much more complex than that. the more we exercise or stimulate the mind. This tendency is caused by the physiology of the mind. Unfortunately. we have a strong tendency to place high value on anything that mirrors our existing reality and low value on everything else. If it is different. Dr. Since new ideas require new connections. and with each firing. idea. Just like building muscles. Page 12 of 20 Excerpt from “Apollo Root Cause Analysis –A New Way of Thinking” 1999 Dean L. a belief. axons and dendrites connect via a synapse. This groove can be an idea. we send all data through what I call a “Delta Checker” from the Greek symbol for difference. this is not a sixties-era song. It is physiological in origin and is found in our search to validate our existing realities. new ideas are at a disadvantage to old ideas existing in physically larger connections. Damasio. if a larger connection provides a preferential path for a neuron firing. but the observation that these neurological connections occur during learning and actually grow in size with repeated exposure to a given stimulus helps explain the physiology behind groovenation. which consist of a cell body. In the thought-provoking book. sometimes it is nearly impossible to pull ourselves out of a groove or rut. The Delta Checker. we analyze it and make a value judgment. Someone who is highly groovenated will remain intransigent even when the path leads directly to a harmful outcome. but it does mean we must remove or modify existing connections to register new thoughts. Each time we have a new thought or experience something new. the connections become physically stronger both in size and chemical response. we like it. a learned strategy. This does not mean we cannot learn.5 It seems that no matter how hard we try. the same physical connections enlarge. we continue to scrutinize it. As we sense the world. including our ideas and thoughts. This is not to suggest that one connection constitutes a specific piece of conscious knowledge. Damasio and others have found the causes of groovenation in the physical nature of the mind. If something is the same as previously known. sense. Descartes’ Error. and input fibers known as dendrites. If we place value on the difference. many synapses are fired. the stronger it gets.4 Antonio R. it is a human condition of the mind that prevents effective problem solving. For every thought. It is the groove we get in by placing a greater value on familiar things than on differences or change. That is. checks for differences between what we are sensing and our existing prototypes. Old connections that are no longer needed are actually dissolved (physically) by special compounds in the brain. a main output fiber called an axon. provides great insights into the working of the mind. occur when neurons become active through an electrochemical process. M. Gano . Brain functions. These neurons are interconnected in circuits and systems within the brain. We have a strong desire to be right in our beliefs. To be groovenated is to hold strong biases and prejudices. or motion. it would explain the physiology of groovenation.. Groovenation is a term I created to describe the process of justifying our beliefs.D. or a habit. The kamikaze pilots in World War II provide a vivid example of a highly groovenated state.Groovenation No. If the same thought or experience is repeated.

As our brains are conditioned into a physical state by the repeated firing of the synapses. The form is filled out. 1994. places (“where” elements). They become valid because of repeated exposure of the mind to the same conditions. Pick any controversial topic—extraterrestrials. overcoming it is a primary focus of becoming better problem solvers. or who has the best football team—and you will find proponents that know the “truth” of their position. and if the solutions will prevent recurrence of the stated problem. What they don’t understand is that their truth is the result of their own brainwashing. repetition of an idea or thought can create a perfect reality that only exists in the mind of the one who created it. Gano . Storytelling Our primary form of communication is through storytelling. ask what the problem is. creationism. consider the people who judge everything they see and proclaim it right or “WRONG!” Groovenation is a natural state of being too focused on being right while ignoring a broader perspective. with many being much worse. athletics. While this was going on. evolution. Understanding the cause of groovenation can help us understand that it is part of being human. It is present in all humans and varies from inconvenience to the paralyzed mind of a fanatic. this is a typical report. a mail person from Central mail pushed the call Page 13 of 20 Excerpt from “Apollo Root Cause Analysis –A New Way of Thinking” 1999 Dean L. Just like practice makes perfect in sports. what the causes of the problem are. and things (“what” elements) in a linear time frame (“when” elements). Because this barrier is deeply ingrained in the human condition.In your daily life. The electrician needed to check the door motor and switches on the top of the elevator car. Incident reports provide prime examples of storytelling and its impact on problem solving. requiring the elevator to remain energized in performing this difficult task. Understanding the physiology behind the process can help us see how easy it is to be brainwashed or to develop an intellect for music. regardless of contradictory evidence. a contractor electrician was conducting an operational check on elevator ELH-23 at TCH-3-675 when a flashover occurred. these relationships will indeed become valid. or whatever we choose. If we spend our lives trying to validate specific relationships. and the categories are defined or discussed. Final Report Incident Date: 10/28/94 Report Date: 1/7/95 Time: 0817 Facility: West Description of Incident: On October 28. The final report below is an example incident report taken from the manufacturing industry and is typical of 60% to 70% of the many incident reports I have seen. Denial is our strongest attribute. Remember. Groovenation presents a formidable challenge to effective problem solving. Storytelling describes an event that relates people (“who” elements). It becomes real. As you read this example. the boxes are checked. we convince ourselves of the absolute validity of our beliefs.

a near-miss with electricity. Corrective Actions: 1. we are told to write stories. notice that the report states that the problem is human error. The investigation discovered the problem to be human error. Aside from this contradiction. 30. are the causes clearly stated? Do the corrective actions support the statement that this will never happen again? What do “position switches” have to do with anything? Also. and corrective actions are being taken to stop this from happening again. Take note of the nice story in the “Description of Incident. The basis for any story is a sequence of Page 14 of 20 Excerpt from “Apollo Root Cause Analysis –A New Way of Thinking” 1999 Dean L. incomplete drawings. Many companies don’t even write the story down. The main fuse blew and the elevator shut down. Due to multiple parties involved in this incident. stories seldom identify causes because they are busy setting the stage of who was where when some action occurred. they get together with the decision makers and tell stories to one another.button on the first floor ignoring the out of service sign posted over the call buttons. but then says the root cause is a defective or failed part. Possible testing procedure to include a better lifted leads and jumpers control log. With the completion of these changes. Root Cause: Defective or Failed Part Is the problem above an injury. Gano .” Not only do we write stories in our incident reports. While entertaining. 1994. Type of Failure: ___Predicted ___Failure Other ___Failure to Secondary Damage ___ Description of Cause: A critique was held on Nov. procedures. Everyone likes a good story. Since these have nothing to do with human error. extensive discussions and management oversight have occurred. additional contradictions are presented. at the incident’s location. but it was a close call. which allowed him to stop the car and exit safely. Provide refresher training to all employees on importance of warning signs. Position switches have been ordered to monitor the length of cable. 2. it was shown to be painfully ill defined and the solutions woefully inadequate. 3. He got control of the car from his location on top of the car. these are cause categories—not causes—to which thousands of solutions could be attached. Revise the electrical drawings to show the complete circuit for the elevator controls. The FCT electrician involved demonstrated step by step actions taken before the maintenance activity. decide which category the problem fits into. The electrician heard a “buzzer” sound and was able to get clear of the moving parts on the top of the elevator car on which he was working before being injured. and implement their favorite solution. 4. or is this simply another example of poor problemsolving skills? After the company further investigated this problem. however. The proposed “Corrective Actions” discuss training. and a position switch. or what? Whatever the problem was. This has caused some delay. something called a flashover. the problem will not recur. Is there a hidden agenda here? Are these vague references listed on purpose.

causing oil to leak and leading to a slippery floor and the accident. Ray Longsine. the root cause is “operators leaving the pumps on during breaks. Ray said this will only occur when the pumps run for an extended period of time (> 4 . causes the oil to get so hot that the foaming is visible through the oil level check window on the pump. this causes the pumps to operate at all times holding 8. We are told that an employee was injured because he fell. I left my name and number and asked him to contact me to let me know how things came out. leading the reader to a significant consequence disguised in a statement like. and identify the right categories. the consensus strategy of a committee is probably at work. fill in the blanks with a good story. and 3) was this the case? Root Cause: In talking to the lead maintenance person. is more than just poor reports. Tom. The employee suffered an “abrasion” just below the left knee that was very painful and swollen. OSHA Recordable Injury Discussion: This afternoon an accident that resulted in an OSHA recordable event at about 7:00 p.” Per Ray.5 minutes). occurring as a sequence of events. it is poor problem-solving skills that are reinforced by poor report writing and rule-based thinking like filling out a form. They indicated they had not. I returned to the area to talk to the lead person. The employee was working in the yellow room on machine #3. the focus is on people. with his left knee hitting the metal legs of the worktable. Few causes are stated. Supervisors and managers are especially frustrated by such reports but are lost for ways to remedy them.events starting at some arbitrary point in the past. and when presented to the class. The concern. and the root cause was operators leaving the pumps on during breaks. He fell because a rubber floor mat slipped. As the example shows. The employee was in a rotating position when the rubber floor mat slipped. I asked Diane if anyone was in the area at the time of the incident and she mentioned “Katy. He said that all employees have Page 15 of 20 Excerpt from “Apollo Root Cause Analysis –A New Way of Thinking” 1999 Dean L. Forms subtly tell users to turn off their brains. and things. My concern is: 1) whether the incident occurred when the employee was alone. Even the stated root cause discussion is mostly story. or the consensus of a group. “The final investigation discovered the root cause to be human behavior. causing the employee to fall to his knees. I returned to the yellow room to investigate the incident. Every time I teach a class to a new client. It is apparent that no one actually witnessed the incident. are then presented as corrective actions. however.” Opinions. and Billlie. Gano . 2) is there a policy about employees working alone in the yellow room. Billie. When corrective actions are disjointed like the ones in this example. I took the employee to the Payton Northeast Hospital emergency room where he was awaiting diagnosis. the most common response is that it is typical or not unusual. I ask them to send sample event reports. I always find one or more that look like the example discussed here. Another example of an incident or event report is shown below.0 psi of pressure which after a prolonged period. but she had gone home for the night. places. check the boxes.” I asked each employee if they had witnessed anything.m. He contacted his mother to pick him up.

or the next time you are in a meeting. and the corrective actions express a pre-established opinion as to what should be done about a condition that somehow may relate to the injury. Or. Is it good that the lion eats the gazelle. pick up any newspaper or magazine. the next time the President of the United States or any other politician speaks. The stronger the storytelling culture. If it is good. It doesn’t matter which culture. Ray indicated that John Sisner had looked into a different type of pump. the problem comes when we fail to understand how categorization can lead to intellectual laziness. we categorize something as good or bad and stop there. the assumption is that the operators are irresponsible and may even think nothing of working on oil-slickened floors. listen carefully. what. It appears that this oil problem is not monitored across all shifts and the oil should have been detected long before it caused an accident. we can ignore the situation and move on to more bad things. All this without ever talking to the injured employee. and then told to be more careful. Talk to your friends. we misrepresent the situation by oversimplification. Corrective Action: Have operators be responsible for checking the machines for oil leaks several times during the shifts for leaks. or is it bad? Neither. He has even checked machines during breaks and provided feedback to those in violation. You will hear all the elements of a story listed above—who. That is. Gano . While categorization is a natural process of the mind. and it is directly proportional to storytelling. “operators left pumps on. they just start leaking oil. the less effective we are at problem solving. the type that is used on the new machines. Once again. and when—but you will not hear many causes. and to assign a categorical answer. Categorical Thinking Categorical thinking is caused by the mind’s need to order what it perceives.been told not to leave the machines energized while they take breaks. A storytelling culture can exist within organizations or within different regions of the country or world. like bad. Ray indicated he had changed out five pumps in the last two months. If you want to observe a storytelling activity. Page 16 of 20 Excerpt from “Apollo Root Cause Analysis –A New Way of Thinking” 1999 Dean L. where. or in this case. which we will discuss in Chapter 2. more responsible.” places blame on the operators. enforce the policy of not leaving the machines on while taking breaks. Ray also indicated that the problem only surfaced about three months ago when a lot of new training was being done. listen carefully. Storytelling sets us up to fail by ignoring causes and the cause and effect principle. country. it simply is. Instead of seeking to understand. We establish a course of action because if it is bad we are compelled to right the injustice and make it good. failed. The root cause. Don’t know what the status is on that. Also. we have a common human affliction of poor problem solving. or education level we observe. The notion of good and bad is categorical thinking at its most base level. by making the operators responsible to check for oil leaks. the employee has been set up to fail. The pumps are such that they don’t go out.

Examples of this categorical thinking are all around us. has questionable data. are evaluated for cause and effect relationships and individually controlled. The following is another common example of categorical thinking. including our garbage. if you are not well educated and I am. Solutions based on categorical causes fail to correct more fundamental causes like the cause of wear. Lumber mills used to burn all their scrap until they finally realized they were polluting the air and wasting valuable raw materials.Please note. I am opposed to categorization. we compare notes and find the same causes in completely different categories. or political alignment. in order to know “who” they are. The Garbage Solution has us put many problems into one category and solve them with one solution. like a banana peel. yet we use this strategy daily because we don’t have time to do otherwise. consistently comparing apples with apples and oranges with oranges is essential. as will be discussed later. it is not the category that causes the problem. Gano . religion. I recommend all categorization be performed by one person or a small cadre of like-minded people. Here are some examples I hear often: “The cause of 95% of all industry accidents is human behavior. Is there anyone among us who doesn’t do this? For example. They are not. Our solution: put these no-value things in the garbage and someone will make them disappear. The problem categorization creates is the belief that once categorized we can establish certain relationships and then act according to our favorite solutions or stop thinking. Categorical thinking creates another significant problem for data collection and analysis. We seek to know where people come from. we solve many problems with one solution. As the two incident reports demonstrate. When completed. We are Page 17 of 20 Excerpt from “Apollo Root Cause Analysis –A New Way of Thinking” 1999 Dean L. Categorization is strongly linked to storytelling. human behavior. Every database that has ever been created from the input of more than one person. When interacting with others. Categorization can be a very helpful strategy. we seek “the biggest bang for the buck!” We put as many problems as we can into a category and then solve it with one solution. Such an inference precludes me from knowing the real you. The end result is recurrence of the event. The danger of this strategy is that it doesn’t address each individual problem and may cause many other problems.” “The pump failed because it was worn out. others. Now most pollutants. The solution to pollution used to be dilution until we looked closer at its effects. may have none. Stopping at categories like “worn out” usually leads to ineffective solutions such as replacing the equipment. the stated causes represent a group of causes.” In these three examples. In any database. Some objects have great value. we have to assess the value of many objects. In business. and worn-out equipment are all categorical causes. As we go through the day. The magnitude of this discovery is significant. we assume there is a single reality and therefore our categories are identical to theirs. like most accident reports. I have run hundreds of experiments where I ask students to categorize a list of causes.” “Corporations have caused most of the environmental disasters in the world. then I can draw certain conclusions and act in a certain way. The Garbage Solution is my favorite example of categorical thinking. That is. corporations. but if it must be done. It appears to be effective and is used extensively in all aspects of our lives. With this strategy. the causes of the events are in categories. their education level. not a specific cause we can act upon.

implement another favorite solution. Effective problem solving means the problem never happens again. the problem is never fully understood and it happens again. “Thank you for coming. Observing thousands of decision-making meetings. we assign value that establishes our biases and prejudices. A focus on solutions. In the process of categorizing. When it does recur.not doing this now because we believe in the notion of a single reality and that everyone “sees” the same world. I found that most meetings start with a statement something like. The battle for the right answer begins and the person with the best story—usually the boss or whoever is considered an “expert”—wins. Categorization is part of our natural operating system. and the cycle continues. As you can see. The belief that the problem is obvious is caused by the belief in a single reality discussed above and the notion that we all think the same (common sense). and the focus is on sharing our favorite solutions to show everyone else how smart we are. Gano . causes are ignored. Little or no synergy occurs. Let’s assess each one of these factors. so does anyone have any ideas how we can prevent this from happening again?” The leader looks around the room and sees everyone nodding their heads in approval. so continues. A few people will offer their solutions and the arguing commences. we set ourselves up with ineffective problem-solving strategies. 3.” but the problems keep recurring. We become so engrossed in tracking and trending causes that we do not realize we are failing miserably. Unknown causal relationships. Quite often the discussion ends with the boss or expert expressing their reality—everyone agrees. Incomplete problem definition. Incomplete Problem Definition Incomplete problem definition is caused by the false belief that the problem is obvious and the subsequent rush to find a solution. 2. The operations manager knows the problem was caused by poor maintenance. Causes of Ineffective Problem Solving As we review the many examples of ineffective problem solving. we discover a recurring trend—effective solutions are not found because of three things: 1. By not recognizing the danger these prejudices bring. I think everyone pretty much knows what the problem is. Page 18 of 20 Excerpt from “Apollo Root Cause Analysis –A New Way of Thinking” 1999 Dean L. and they move to implement that person’s wishes. the problem is not defined. Most people have been in this meeting. we reconvene the meeting. We track and trend how many times we have certain types of failures and create beautiful graphs and charts showing the various “root causes. Everyone is nodding in approval but is thinking many different things. The maintenance manager knows it was those darn operators again. and the facility manager knows somebody screwed up again.

therefore. Focusing on solutions is caused by many things. We infer that hardware wore out by recommending replacement.” is required to adequately understand the problem. we stop at causes that align with a favorite solution. not prevent recurrence. we validate the rightness of our search and cease to look any further. Monetary penalties did nothing that I am aware of to prevent future oil spills. Why did the hardware wear out? This. we often find ourselves solving the wrong problem. Instead. We talk in terms of human error.’” The “real” world will be their world. the purpose of the legal system is to punish. It is important to remember that groovenation is a strong physiological force and that even the best and the brightest can succumb to it. Our ignorance of the cause and effect principle as discussed in the next chapter is perhaps the largest contribution to incomplete causal analysis. My daddy drove a Ford and his daddy drove a Ford. and it prevents effective problem solving most of the time.Unknown Causal Relationships Causal relationships often remain unknown because we do not seem to think causally. not ours. Instead of continuing to ask “why” to our point of ignorance. Shoot. and other categorical causes like management being less than adequate. This tendency to seek the familiar is called the favorite solution mindset. I will always drive a Ford. The “Ready. lack of training. Today. (Note: While this is a sad truth. This kind of logic is a natural mental process whereby we seek the familiar and call it “right” or “real. Aim!” personalities are hard to deal with because they are ensconced in categorical thinking and buoyed by past successes (groovenation). As discussed earlier. but chief among them is groovenation. Gano . The federal government focused on this issue as the problem and proceeded to penalize the Exxon Corporation as the main solution. I have attempted to show that we are set up to fail by the processes and strategies we use. along with several more “whys.” We tell our children “wait until you grow up and have to face the ‘real world. and the inferences surrounding the stories pass as causes. Groovenation and Page 19 of 20 Excerpt from “Apollo Root Cause Analysis –A New Way of Thinking” 1999 Dean L. Authoritative and goal-driven personalities contribute to this drive to find a quick solution. Set Up to Fail By sharing my observations of the current state of problem solving. A Focus on Solutions By focusing on solutions without clearly defining the problem and its causes. and it will be much different. we communicate by telling each other stories.) Industry efforts to install double-hulled tankers has done more to prevent recurrence than the fines levied on Exxon. our brains are wired such that we search for what we already know and when we find it. most people still believe the Exxon Valdez oil spill was caused by a drunk captain.

It also helps us break the bonds of groovenation by presenting legitimate realities heretofore unknown. 4 Descartes’ Error. we have never had the tools to allow us to create a common view or understanding—to form what I call a common reality. Boise. Robert Ornstein and Richard F. M. they would be a big skewer. New York. Stoutenburg as part of his graduate work in Instructional and Performance Technology at Boise State University. 1984.D. Conformity. we align our thoughts into one point of view. With many diverse thoughts. Up until now. New York..D. not individuality. Restak. is the enemy of effective problem solving. Houghton Mifflin Co. there is no limit to what we can accomplish. Bantam Books. when in fact it is our greatest strength. Robert Ornstein and Richard F. each providing a small support and together supporting all the weight. as individuals. and they will help us get out of this mess. Unfortunately. Thompson. By creating a common reality made up of all perspectives. These tools are based on the cause and effect principle discussed in the next chapter. 1984. we are able to break out of the illusion of common sense and thus prevent the usual arguing that prevails. Gano . single reality. Antonio R. If they were all aligned in a row. these strategies set the formula for ineffective problem solving. 2 The Amazing Brain. What we need is some way to express every stakeholder’s perspective in a way that complements the learning process. we can create a common view greater than any individual reality. 3 The Amazing Brain. Thompson. Creating this common reality is what Apollo root cause analysis is all about. we often look on individuality as counterproductive to effective teamwork. 1994. 1994. Richard M. Grosset & Putnam. When we conform. Page 20 of 20 Excerpt from “Apollo Root Cause Analysis –A New Way of Thinking” 1999 Dean L. Idaho. Together. When coupled with the misguided belief in a single reality and the illusion of common sense that this creates. Boston. Given proper tools that overcome the handicaps of existing strategies like common sense. The remaining chapters are as follows: Chapter 2: Understanding the Cause and Effect Principle Chapter 3: Solving Problems Effectively Using Apollo Tools Chapter 4: Identifying Effective Solutions Chapter 5: Implementing Solutions Chapter 6: Facilitating Groups Chapter 7: A New Way of Thinking Appendix: Comparison of Common Root Cause Analysis Methods 1 Performed by James M. Boston. The guru is not skewered because his weight is distributed over many individual points. Houghton Mifflin Co.. The nails together as individual units support the body. categorization.. M.the unintended pursuit of the ignorance it creates are the driving factors in this setup. 1994.. and the pursuit of a root cause. 5 Receptors. Damasio. storytelling. The diversity each person brings to the table provides the opportunity to see a bigger and clearer picture of each situation. we can find effective solutions to everyday problems almost every time. The bed of nails supporting the East Indian guru can illustrate this principle.

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